Loading...Download MetLife Dental Claim Form. This form is used to file a claim with MetLife Dental for expenses or for your dentist to file to receive payment. Complete this form to receive reimbursement or to pay directly to the dental provider.
How To Write
Step 1 – This is to be completed by employee :
- You Must Review The Important Statements On Page 2 and Sign Where Indicated Prior To Completing The Patient Section of This Form
Step 2 – Section 1 – Complete blocks 1 through 22 as follows:
- 1. Patient First Name, Middle, Last
- 2. Relationship to Employee (check one)
- 3. Sex (check one)
- 4. Married (check yes or no)
- 5. Patient Date of Birth mm/dd/yyyy
- 6. For Office Use Only- Do Not Mark In Box # 6
- 7. If You are a Full Time Student 19 or Over:
- School, City, State
- 8. Employee Social Security Number/ID number
- 9. If Disabled (check yes or no)
- 10. Name of Group Dental Program
- 11. Employee First Name
- 12. Employee Date of Birth mm/dd/yyyy
- 13. Office Phone Number (with area code)
- 14. Employee Residence Mailing Address
- 15. City, State, Zip
- 16. Are Other Family Members Employed (check yes or no) If yes – Name and SSN/ID
- 17. Date Of Birth mm/dd/yyyy
- 18. Name and Address of Employer for Item 16
- 19. Is Patient Covered By Another Dental Plan? (check yes or no) – If yes complete the following:
- Dental Plan Name, Group Number, Name and Address of Carrier
- 20. Signature of Patient or Authorized Agent if Patient is a Minor:
- Signature, Date mm/dd/yyyy
- 21. I Certify That The Information Above Is Correct Employee Signature, Date mm/dd/yyyy
- 22. I Authorize Payment Directly To The Below Named Dentist
- Employee Signature, Date mm/dd/yyyy
Step 2 – This Section ( blocks 23 through 40) Is Only To Be Completed By The Dentist.
- When Complete, Dentist Will Mail for Review and Payment